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Volume 9, Number 6 June 2006 - National Diabetes Education ...

CLINICAL INSIGHTS ®IN DIABETESCOMMENTARYSaul Genuth, MD. Professor of Medicine, Case Western Reserve University School of Medicine,Cleveland, Ohio.This observational Scottish study, which compares CVD outcomes in type 2 diabetic patients receiving metforminalone, a sulfonylurea (SU) drug alone, or combinations of the two prescribed in either sequence, demonstratesgreater total and CVD mortalities in all SU drug-use categories. This continues the controversy generated by the1970 University Group Diabetes Program finding of increased CVD risk with an SU drug. However, there is animportant difference. The earlier study compared an SU drug to a placebo in a randomized clinical trial. The currentobservational study's findings can as well or even better be interpreted as a beneficial effect of metformin onCVD outcomes, as previously robustly shown by the UKPDS randomized trial. Other findings of the Scottish studythat are difficult to explain raise cautionary flags, ie, the CVD risk decreased significantly with increasing systolicblood pressure and with increasing A1C, contrary to extensive literature showing the opposite. Moreover, initialprescriptions for drugs do not necessarily equal constant use of these drugs during the observational period. Forthese reasons, this study should not be employed to further incriminate SU drugs, whose use to improve β-cellfunction in type 2 diabetes is still pathophysiologically justifiable.Clinical Insights ® in Diabetesis now available througha new channel ofdistribution via Podcast.To participate in thisCME activity via Podcast,please visit us online atwww.ndei.org.Regression of Coronary Atherosclerosis WithIntensive Statin Therapy: The ASTEROID TrialAtherosclerosis is characterized by ongoingplaque accumulation within the arterial wall.The introduction of statins has revolutionizedthe treatment of dyslipidemia. Current guidelinesrecommend aggressive low-density lipoproteincholesterol (LDL-C) target levels (50% luminal narrowing throughout aminimum-length 40-mm target segment. Coronaryatheroma burden was determined in 349patients using IVUS at baseline and after 24months of treatment with rosuvastatin 40 mg/day.The primary endpoints were change in PAV andnominal change in total atheroma volume inthe 10-mm subsegment with the greatest diseaseactivity at baseline. The secondary endpointwas change in normalized total atheromavolume for the entire artery. Ethical considerationsprecluded randomizing a control group ofpatients on low-intensity treatment.In the study group, the mean age was 58.5years, 70.2% of patients were male, 96.8% werewhite, and 24.6% had a history of myocardialinfarction. By endpoint, the mean LDL-C level ±standard deviation (SD) had significantly decreasedby 53.2%, from 130.4 ± 34.3 mg/dL to60.8 ± 20.0 mg/dL (P

CLINICAL INSIGHTS ®IN DIABETESThe ASTEROID TrialContinuedaccepted guidelines, when associated with significantincreases in HDL-C levels, can lead toregression of coronary atherosclerosis. A linearregression analysis of the results of the ASTEROIDtrial, along with results of other major statintrials, revealed that median change in PAV isclosely related to mean achieved LDL-C levels(r 2 =0.97; P25 kg/m 2 ), middle-aged (40–64 years)men (n=172) and women (n=350) with impairedglucose tolerance (World Health Organization1985 criteria) were randomized to receive eitherstandard care (control group) or intensive dietaryand exercise counseling. At baseline, mean ageof participants was 55 years, mean BMI was31 kg/m 2 , and 63% of patients had at least oneparent with diabetes. Study participants wereadvised to lose weight, increase physical activity,and consume a moderate-fat (total fat

CLINICAL INSIGHTS ®IN DIABETESClinical Insights ® in Diabetes Post-Test June 20061) Regarding the ASTEROID trial, which of the following statements is false?a. High-dose statin treatment decreases the volume of atheroma in coronary arteries.b. The reduction of atheromas was associated with fewer cardiac events in this study.c. High-dose statin treatment decreased LDL-C levels by more than 50%.d. High-dose statin treatment in this study was not associated with rhabdomyolysis.2) In the Lindström study, which factor did not lead to a reduced risk for developingtype 2 diabetes?a. Low saturated fat intakeb. Low total fat intakec. Weight reductiond. Low fiber intakee. Increased physical activityNDEI MISSION STATEMENTThe National Diabetes Education Initiative ®(NDEI ® ) is a multicomponent educationalprogram on type 2 diabetes designed forendocrinologists, diabetologists, cardiologists,primary care physicians, and otherhealthcare professionals involved in the careand management of patients with type 2diabetes and insulin resistance. NDEI programsaddress issues concerning insulinresistance and type 2 diabetes, from theepidemiology and pathophysiology of thedisease and its associated complications tothe therapeutic options for treatment andprevention.You have received this email because webelieve it may be of interest to you. If youwould like your name to be removed from ourmailing list, please choose from the following:1) Reply to this email and place REMOVEin the subject line.2) Call 1 (800) 873-1362 and leave amessage with your name and emailaddress indicating that you would liketo be removed.National Diabetes Education Initiative, NDEI,and Clinical Insights are trademarks usedherein under license.Copyright © 2006 Thomson ProfessionalPostgraduate Services ® . All rights reserved.EM-T177-06-PHYCME-06063) Based on the study of sulfonylurea (SU) therapy and risk of cardiovascular (CV) events,which of the following statements is false?a. There is increased CV mortality in patients receiving SU monotherapy compared withthose receiving metformin monotherapy.b. There is increased CV mortality in patients receiving initially combined SU andmetformin therapy compared with those receiving metformin monotherapy.c. Adding metformin to SU monotherapy decreases risk of CV mortality compared tometformin monotherapy.d. Adding SUs to metformin monotherapy increases the risk of CV mortality.e. It is unclear whether metformin has a protective effect or SUs have adeleterious one.ANSWER KEY1) b. The reduction of atheromas was associated with fewer cardiac events in this study. Although resultsof this study suggested that high-dose statin therapy may lead to regressive atherosclerosis, the studywas not designed to show clinical outcomes of this effect.2) d. Low fiber intake. Low saturated fat and total fat intake, increased physical activity, weightreduction, and high fiber intake are all associated with decreased risk for developing type 2 diabetes.3) c. Adding metformin to SU monotherapy decreases risk of CV mortality. Patients started on SU therapyremained at increased risk of CV mortality after metformin therapy was added to their treatment.For more information about upcoming NDEI CME and CE activities, visit us at www.ndei.org orcall 1 (800) 606-6106. Visit www.ppscme.org for information on other CME or CE activities.Clinical Insights ® in Diabetes is co-edited by NDEI faculty members Mayer A. Davidson, MD, and Silvio E. Inzucchi, MD.If you have any friends or colleagues who are not receiving this free, CME e-newsletter via email, pleasefill in their information on the lines below and fax this page back to us at 1 (800) 471-7716 and we willadd them to our subscriber list.Name: (Please print) ______________________________ Specialty: _______________________________Email Address: _____________________________________________________________________________4W:\NDEI\Clinical Insights\T177 Clinical Insights\June 2006\June 06 NEWSLETTER MAIL COLOR 6-23.doc

CLINICAL INSIGHTS ®IN DIABETESActivity Code: T177-06Issue Date: June 2006CME Credit Availability: August 2006CME Activity Evaluation/Registration FormParticipants who wish to obtain CME credit for this activity, please complete the contact informationbelow, sign this form, and fax it with the completed post-test to (201) 430-1441 or mail to:Thomson PPS ® , CME Dept. T177, PO Box 1505, Secaucus, NJ 07096-1505. You may download previousissues of Clinical Insights ® in Diabetes e-newsletters by visiting us online at www.ndei.org.I completed this activity as designed: _____________________________________________________________________________________(Signature)PLEASE PRINT CLEARLY:Name:Address:City:Phone:Email Address: State: ZIP Code: - - Fax: - - Professional Classification: MD DO PharmD RN NPOther ____________________________________________________________________Specialty: Endocrinology Cardiology Internal medicine Primary careOther _________________________________________________________________________________________Overall Program1. The activity met the stated objectives in such a way that I am better able to:StronglyDisagree Disagree AgreeStronglyAgreea. Select an appropriate therapeutic regimen for patients with type 2 diabetes andthe metabolic syndrome 1 2 3 4 5 6b. Summarize risk factors for cardiovascular disease in patients with type 2 diabetesand the metabolic syndrome 1 2 3 4 5 62. Overall, the activity was presented in a fair-balanced manner. Yes No** If you checked “No,” please explain.3. In reflecting on your practice, what type of impact will this educational activity have?This program has validated my practice in the treatment of type 2 diabetes and its cardiovascular complications.Need more information before making a change.(Please specify what information you would require.)I will:Identify patients with type 2 diabetes and the metabolic syndromeSelect an appropriate therapeutic regimen for patients with type 2 diabetes and the metabolic syndromeOther (Please specify.)4. What topics should be dealt with in more detail? (List topics)Thank you for your participation.5

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